Belly Pain and Vomiting: When to Worry? - Pediatric Nursing

Belly Pain and Vomiting:
When to Worry?
Judith J. Stellar, MSN, CRNP
Surgery Clinical Nurse Specialist
The Children’s Hospital of Philadelphia
ABDOMINAL PAIN
TRAUMA??
NO YES
Perforation
Hemmorrhage
Hematoma
AGE??
Contusion
ACUTE
CHRONIC
Peritonitis
GER, Milk Allergy,
Obstruction
SCC, IBD
Rectal Bleeding Constipation
Functional Disorders
INFANTS: Birth to 1 Year
• NEWBORNS
– Anomalies of the GI
tract
– NEC
– Perforation
– Volvulus
• INFANTS up to 1 year
– Colic, Constipation
– Gastroenteristis
– UTI
– Incarcerated Hernia
– Intussusception
– Volvulus
– Hirschsprung’s Disease
TWO TO FIVE YEARS
• Gastroenteritis
• Constipation
• Appendicitis
• UTI
• Intussusception
• Volvulus
• Trauma
• Sickle Cell
• HSP
• Pharyngitis
SCHOOL AGE: 6 to 11 Years
• Appendicitis
• Gastroenteritis
• Constipation
• Functional pain
• UTI
• Trauma
• Sickle Cell
• HSP
• Mesenteric Adenitis
ADOLESCENTS: 12 to 18 yrs.
• Appendicitis
• Ovarian / Testicular
Torsion
• IBD
• Gastroenteritis
• Constipation
• Dysmenorrhea
• Mittelscherz
• PID
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Is All Belly Pain The Same?
• Visceral Pain
– Irritation to viscus tension, stretching, ischemia
– Visceral pain fibers: bilateral, unmyelinated, enter
spinal cord at various levels
– Pain: dull, poorly localized and midline
• Parietal Pain
– From the body wall, peritoneum
– Myelinated fibers to specific dorsal root ganglia
– Pain: sharp, intense, localized
– Aggravated by movement or coughing
• Referred Pain
– Similar to parietal pain
– Results from shared central neuron pathways
– Pain: felt in distant location--Shoulder, Flank
STEPWISE APPROACH
• HISTORY
– Medical, Surgical, Family
• REVIEW OF SYSTEMS
– Sequence of events, Extra-intestinal
symptoms, Growth failure, Weight loss,
Recent illness
• THOROUGH PHYSICAL EXAM
• Laboratory Studies
• Radiologic Studies
HISTORY: RED FLAGS
• Young age
• Pain History indicating
acute process
• Poor growth or weight
loss
• Rash, Joint pain
• Blood in stool
• Blood in Urine
• Multiple sexual
partners, unprotected
sex
ABDOMINAL PAIN:
RED FLAGS
• Age of patient
• Pain aggravated by movement
• Well-localized pain
• Night time awakening; restriction of activities
• Poor growth / weight loss
• Associated symptoms: vomiting, diarrhea,
urinary tract symptoms, respiratory, sore throat
• Extra-intestinal manifestations: rash, mucosal
ulcers, joint pain
• Abnormal physical exam
• Abnormal labs +/- radiographic studies
VOMITING
When Should You Worry?
Bilious emesis
is a surgical
emergency
until proven
otherwise.
• Bilious
• Bloody
• Associated with other
symptoms
• Poor Growth
• Electrolyte imbalance
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Physical Exam:
General Appearance
• Moving?
• Involuntary guarding?
• Color: pale, jaundice, rash, purpura
• Breathing pattern
• Hydration status
• Development
Physical Exam: Inspection
• Contour
• Scars, Bruising
• Hernias
• Visible Peristaltic Waves
Physical Exam
• Auscultation
– Bowel sounds
• Percussion
– Dullness, Tympani
• Palpation
– Superficial then deep
– Painful area last
– Voluntary vs Involuntary
Guarding
– Peritoneal Signs?
– Rebound tenderness
FIGURE 1B. Anatomic
basis for the psoas
sign: inflamed
appendix is in a
retroperitoneal location
in contact with the
psoas muscle, which is
stretched by this
maneuver.
FIGURE 1A. The psoas sign. Pain on passive
extension of the right thigh. Patient lies on left
side. Examiner extends patient's right thigh
while applying counter resistance to the right
hip (asterisk).
FIGURE 2B.
Anatomic basis for
the obturator sign:
inflamed appendix
in the pelvis is in
contact with the
obturator internus
muscle, which is
stretched by this
maneuver.
3

Radiologic Work-Up
FIGURE 2A. The obturator sign. Pain on
passive internal rotation of the flexed thigh.
Examiner moves lower leg laterally while
applying resistance to the lateral side of the
knee (asterisk) resulting in internal rotation of
the femur.
• Plain Films
– CXR: r/o
pneumonia
– Air-Fluid Levels
– Free Air
– Masses, FB,
Calcifications
• Contrast Studies
• Ultrasound
• CT
Plain Films
Plain Films
Free Air
Dilated Loops
Fecalith
Air-Fluid Levels
Laboratory Work-Up
• CBC, with differential (? Bandemia)
• Chemistries
• Urine pregnancy test
• Urinalysis
• +/- LFT’s, amylase, lipase
• +/- Rapid Strep
• Stool studies: occult blood, culture, white cells
Constipation
4

Normal
Rotation
5 th Week
5 th week
8 th week
Malrotation
10 th week
11 th week
MALROTATION
Malrotation
• Failure of normal rotation & fixation
• Abnormal bands form
• Free floating bowel twists around SMA
• Diagnosed with UGI
• If found incidentally surgery still
performed
• 2-3 hours of compromised blood supply
leads to gut necrosis
5

Division of Ladd’s Bands
Spreading the Mesentary
SMA Syndrome
SMA Syndrome
SMA Syndrome
Ovarian Cyst
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Giant Mesenteric Cyst
Ovarian Torsion
Pelvic
Inflammatory
Disease
Ovarian Cyst with Torsion
Treatment:
Medical
Antibiotics
Counseling
Acute Abdomen
• Definition - Any intra-abdominal condition
requiring urgent surgical intervention.
• Etiology
1. Abdominal Inflammation/ Peritonitis:
NEC, perforated appendicitis, infection,
pancreatitis
2. Obstruction: gut ischemia and necrosis
with subsequent perforation
3. Perforation: Blunt or penetrating trauma,
IBD,anastomotic leak, iatrogenic cause
4. Hemorrhage: vascular injury
Pathophysiology of
Peritonitis and Perforation
Solid Organ Injury
or Vascular Injury
Hemoperitoneum
Lysed RBC
Peritonitis
(Acute Abdomen)
Increase Capillary Permeability
Capillary Leak-Transudation
(3 rd Spacing)
Hypovolemia, Shock, Death
Perforation of Hollow Viscous
Leakage of GI Contents
Localized Abscess
- Less acute process
- Pain, fever
- Interval OR
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APPENDICITIS
• Most common acute
surgical condition of the
abdomen
• 7% of the population
affected
• Peak age: 10 to 30 years
• Diagnosis: Based on H & P
• Can be very unpredictable
APPENDICITIS
• Classic Symptoms: PAIN-
Periumbilical then localizes
to RLQ, followed by nausea
and vomiting, fever
• Only 50% of cases present
this way
• Onset of symptoms over 12
to 24 hours
• Perforation thought to be at
about 36 to 48 hours after
onset of symptoms
APPENDICITS
• Appendix may lie in
a variety of
positions, including
retrocecal
• Up to 30% of cases
may have a ―hidden‖
appendix, thus
affecting the disease
presentation and
physical exam
APPENDICITIS: WORK UP
• History-pulmonary Sx, sore throat?
– Sequence of events: pain first?
• Physical Exam-include rectal exam
– Peritoneal Signs?
– pelvic exam for adolescent girls
• Plain Films
– CXR, Obstruction Series
• Laboratory
– CBC w/ diff, UA, HCG, Chemistries
– Stool cultures
• Ultrasound; Abdominal CT
8

Thickened Appendix with
Suppuration at Tip
Appendix with Fecalith
Inflamed Appendix
Perforation
9

Appendiceal Abscess
IBD: Clinical Presentation
• Delayed surgical
intervention can result in
abscess formation
• Attempt IR drainage
• PICC line and IV
Antibiotics 10 to 14 days
• Readmit for ―Interval
Appendectomy‖
• Poor growth, weight loss
• Poor appetite, nausea, vomiting
• Anemia, fatigue, malaise
• Extra-intestinal manifestations: fever,
joint pain, uveitis, rash, mouth ulcers
• Malabsorption: abdominal pain/
cramping, frequent loose stools with
mucous and/or blood.
• Perianal disease: fistulas
Urgent Intervention in Crohn’s Disease
Severe Inflammation with impending perforation
Abscess secondary to fistulous or perianal disease
Stricture
Gall Bladder Disease
• Biliary Colic
• Acute Cholecysitis
• Acute Cholangitis
• Biliary Pancreatitis
Gall Bladder Disease
10

Abdominal Trauma
• More often blunt injury
• Blunt trauma treated conservatively unless
there is clinical deterioration
– Includes bedrest, serial exams, serial labs
and films, slowly liberalize activity
• Vascular injury and hemoperitoneum causes
peritoneal irritation--operative intervention if
hemodynamically unstable
• Perforative injury requires urgent surgical
intervention
LIVER FRACTURE
Seat Belt Injury:
Bowel Wall Thickening
Seat Belt Injury:
Abscess
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Pancreatic Trauma
―Don’t Mess with the Pancreas‖ M. Nance, MD
• Different than liver or spleen
• This is a glandular organ—very secretory
• Can have diffuse pancreatitis with autodigestion of
surrounding tissues
• May or may not subsequently develop a pseudocyst
• Requires bowel rest and conservative management
• ERCP for stent placement to internally drain
pseudocyst
• Open surgical intervention (―cystgastrostomy‖) last
resort
FIGURE 2. Contrast-enhanced axial computed tomographic
section of the upper abdomen showing peripancreatic and
retroperitoneal edema (large arrows) and stranding. The
pancreas itself (small arrow) appears relatively normal
Pancreatic Pseudocyst
JEJUNAL
PERFORATION-
15 mo. girl
s/p abuse
Meckel’s Diverticulum
• Remnant of omphalomesenteric duct
• Located on antimesenteric border of terminal
ileum within 60cm of: ileocecal valve
• 57% are lined with ectopic gastric mucosa
often leading to ulceration & painless
hemorrhage
• Also can lead to diverticulitis, intussusception,
obstruction, perforatioon, requiring surgical
intervention
12

Diagnostic Test: ―Meckel’s Scan‖
Nuclear Med Scan where isotope is taken up by
gastric mucosa, whether within the stomach or
ectopic.
Meckel’s Diverticulum
Intussusception
• Folding of the intestine into
itself (telescoping)
• Second most common cause
of intestinal obstruction
• 90% near the ileocecal valve
• Lead Points: Meckel’s, polyp,
tumor, anastomosis
• Gastroenteritis
Hyperperistalsis
• 5% of cases recur after
treatment
Signs and Symptoms
Intussusception
• Sudden onset of intermittent, crampy
abdominal pain
• Anorexia
• Vomiting (nonbilious then becoming bilious)
• Irritable, then lethargic between episodes
• Currant jelly stool (heme positive)
• Tachycardic, hypotensive, temperature
elevation-late signs (impending necrosis)
Radiographs
• Plain Film - paucity of gas and stool in
the colon
• Air or Barium Enema - can be both
diagnostic and therapeutic
– Surgeon present for contrast enema
– IV access: fluids, sedation, pain relief, and
antibiotics
13

Barium
Enema-
Identification of
Intussusception
Reduced
Intussusception
with filling of the
appendix.
Ileo-Ileal Intussusception
Surgical Treatment
• Indications
– Failed air or barium reduction
– Evidence of bowel perforation or peritonitis
• Surgical Management
– Transverse incision (RLQ)
– Manual reduction
– Resection and end-to-end anastomosis
– Incidental appendectomy
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